Lipid Screening In Children Research Articles

Lipid Screening in Children and Adolescents—A Missed Opportunity to Improve Lifelong Health

Lipid Screening in Children and Adolescents—A Missed Opportunity to Improve Lifelong Health

Familial hypercholesterolemia in China requires greater efforts

Familial hypercholesterolemia in China requires greater efforts

Adherence With Lipid Screening Guidelines in Children With Acquired and Congenital Heart Disease: An Observational Study Using Data From The MarketScan Commercial and Medicaid Databases.

BackgroundUniversal lipid screening in children provides an opportunity to mitigate the lifetime risk of atherosclerosis, particularly in children with chronic conditions that are predisposed to early atherosclerosis. In response, national guidelines recommend additional early screening in a subset of cardiac conditions. The penetration of such guidelines has not been evaluated.Methods and ResultsWe performed a retrospective study of a geographically representative sample of US children using the MarketScan Commercial and Medicaid claims databases. The study population was children with cardiac disease between ages 2 and 18 years and ≥3 years of continuous coverage from January 1, 2013, to June 30, 2018, divided into 4 major strata of heart disease. We assessed the likelihood of screening between these classifications and compared with healthy children and calculated multivariate models to identify patient factors associated with screening likelihood. Of the eligible 8.4 million children, 155 000 children had heart disease, of which 1.8% (31 216) had high‐risk conditions. Only 17.5% of healthy children underwent lipid screening. High‐risk children were more likely to be screened (odds ratio [OR], 2.1; 95% CI, 2.09–2.19; P<0.001) than standard‐risk children, but that likelihood varied depending on strata of cardiac disease (22%–77%). Timing of screening also varied, with most occurring between ages 9 and 11 years. Among cardiac conditions, heart transplantation (OR, 16.8; 95% CI, 14.4–19.7) and cardiomyopathy (OR, 2.9; 95% CI, 2.8–3.1) were associated with the highest likelihood of screening.ConclusionsChildren with cardiac disease are more likely to undergo recommended lipid screening than healthy children, but at lower rates and later ages than recommended, highlighting the importance of quality improvement and advocacy for this vulnerable population.

Abstract 14696: The Effectiveness of a Unique Community Health System in Detecting Familial Hypercholesterolemia in Kagawa, Japan

Introduction: Familial hypercholesterolemia (FH) is an autosomal hereditary disease found in patients who have elevated low-density lipoprotein cholesterol (LDL-C) levels from birth. Early detection and treatment of FH during childhood potentially reduces the risk of premature cardiovascular events. In Kagawa prefecture, a unique community health system, involving three steps, has been conducted to prevent lifestyle-related diseases for 10-year-old children. This system includes universal lipid screening, selection by pediatricians, and next-generation sequencing (NGS) of FH-related genes in the hospitals. The aim of this study is to investigate whether this system can be effective in detection of FH. Methods: In Kagawa prefecture, the universal lipid screening of children at 10 years of age is performed annually at school, covering over 90% of the target group. After excluding secondary hypercholesterolemia, pediatric clinics introduced children with LDL-C levels &gt;140 mg/dL to four hospitals to perform NGS to detect FH. Results: In 2017, 279 children (3.7%) showed elevated LDL-C &gt;140mg/dL among 7,647 ones who received the screening. We performed NGS for 46 children after excluding secondary hypercholesterolemia by pediatricians (LDL-C 186.0±50.3 mg/dL; M/F 27/19) and 26 children (57%) had FH genetic mutations (23 LDL-R, 3 PCSK9). The children with LDL-C &gt;180mg/dL are recommended to receive statin therapy according to the guideline from the Japanese Atherosclerosis Society (JAS). Children with LDL-C levels ≥180 mg/dL have 74% of positive genetic mutations, and even those with 140-180 mg/dl LDL-C levels have as much as 44%, respectively (Table). Conclusions: The unique community health system in Kagawa can efficiently detect FH of children. Further investigation will be required for the effective prevention of future atherosclerotic cardiovascular diseases.

Quality Improvement Intervention for Universal Lipid Screening in Children Aged 9 to 11 Years.

We performed a quality improvement intervention to increase universal lipid screening in well-child visits (age 9 to 11 years): 12-month preintervention; phase 1 (8 months) with provider education, group monthly chart review with feedback, and electronic health record cues to order lipids; and phase 2 (16 months) with electronic health record cues and examination room phlebotomy. Outcomes were compared with clinics having no intervention. In phase 1, immediate treatment effect on the regression line for provider behavior (proportion of visits with lipids ordered) showed 34% increase in intervention and 7% decrease in comparison clinics; patient behavior (phlebotomy completed) showed 19% increase in intervention and 5% decrease in comparison clinics. At the beginning of phase 2, the intervention clinic had average 44% orders entered and 33% phlebotomy completed per well-child visit, and these proportions were maintained. Provider education and chart review with feedback were associated with the greatest gains in outcomes.

Clinically Actionable Hypercholesterolemia and Hypertriglyceridemia in Children with Nonalcoholic Fatty Liver Disease

To determine the percentage of children with nonalcoholic fatty liver disease (NAFLD) in whom intervention for low-density lipoprotein cholesterol or triglycerides was indicated based on National Heart, Lung, and Blood Institute guidelines. This multicenter, longitudinal cohort study included children with NAFLD enrolled in the National Institute of Diabetes and Digestive and Kidney Diseases Nonalcoholic Steatohepatitis Clinical Research Network. Fasting lipid profiles were obtained at diagnosis. Standardized dietary recommendations were provided. After 1 year, lipid profiles were repeated and interpreted according to National Heart, Lung, and Blood Institute Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction. Main outcomes were meeting criteria for clinically actionable dyslipidemia at baseline, and either achieving lipid goal at follow-up or meeting criteria for ongoing intervention. There were 585 participants, with a mean age of 12.8 years. The prevalence of children warranting intervention for low-density lipoprotein cholesterol at baseline was 14%. After 1 year of recommended dietary changes, 51% achieved goal low-density lipoprotein cholesterol, 27% qualified for enhanced dietary and lifestyle modifications, and 22% met criteria for pharmacologic intervention. Elevated triglycerides were more prevalent, with 51% meeting criteria for intervention. At 1 year, 25% achieved goal triglycerides with diet and lifestyle changes, 38% met criteria for advanced dietary modifications, and 37% qualified for antihyperlipidemic medications. More than one-half of children with NAFLD met intervention thresholds for dyslipidemia. Based on the burden of clinically relevant dyslipidemia, lipid screening in children with NAFLD is warranted. Clinicians caring for children with NAFLD should be familiar with lipid management.

Familial Hyperlipidemia Screening, Treatment and New Considerations

We present a case of a 47-year-old male who came to the endocrinology department at the request of his GP. He was noted to have elevated lipid levels, twice the normal range. Genetic testing was performed which showed he was heterozygous for familial hypercholesterolemia (FH). His three children subsequently had their lipid levels tested. They all had elevated lipids (cholesterol and LDL) and tested positive for FH. This case highlights the importance of lipid screening in children as the prevalence of FH is 1 in 200, which is higher than previously thought. This has led to the underdiagnosis of FH in both the pediatric and adult population. Often on initial presentation of the disease, irreversible damage has been done increasing the patients’ morbidity and mortality. With newer drugs being introduced and the persistent push by the National Heart, Lung and Blood Institute Expert Panel towards initiating a child screening protocol, there is hope that this disease will be manageable and less detrimental to

Updated guidelines for lipid screening in children and adolescents.

Elevated serum lipoproteins in childhood and adolescence are associated with health consequences and poor outcomes in adulthood. Universal screening, recommended in recent guidelines from the National Heart, Blood, and Lung Institute and supported by the American Academy of Pediatrics, may help identify a significant number of children who would be missed by targeted screening.

A systematic review and meta-analysis on screening lipid disorders in the pediatric age group

Background:Different viewpoints exist about lipid screening in all children or only in children with positive family history (FH) of premature cardiovascular diseases (CVDs) or hypercholesterolemia. This systematic review and meta-analysis aim to assess the effectiveness of lipid screening in children and adolescents according to the existence of positive FH of CVD risk factors.Materials and Methods:PubMed, Scopus, and Google scholar were searched to identify relevant papers that were published from November 1980 until 30 November 2013. Irrelevant studies were set aside after studying their title, abstract, and full text. Then, the relevant studies were assessed by using a quality appraisal checklist. We used random effect model for meta-analysis and calculating the total estimation of sensitivity, specificity, and the positive predictive value (PPV) of FH in predicting dyslipidemia among children and adolescents.Results:Overall, 17,214 studies were identified in the primary search, out of which 19 primary studies were qualified for study entry. The sensitivity of positive FH of premature CVD or dyslipidemia for predicting dyslipidemia among children varied between 15 and 93. Moreover, the effectiveness of screening children for dyslipidemia according to premature CVD or dyslipidemia in their relatives was low in 86.9% of the primary studies. The total estimation of sensitivity, specificity, and predictive value was 42.6, 59, and 20.7, respectively, according to the meta-analysis results.Conclusion:The present meta-analysis indicated that selecting target population for screening children and adolescents for dyslipidemia according to their FH has low sensitivity.

Lipid screening in children and adolescents in community practice: 2007 to 2010.

Integrated guidelines on cardiovascular health and risk reduction in children issued in 2011 newly recommended universal screening for dyslipidemia in children at 9 to 11 years and 17 to 21 years. We determined the frequency and results of lipid testing in 301 080 children and adolescents aged 3 to 19 enrolled in 3 large US health systems in 2007 to 2010 before the 2011 guidelines were issued. Overall, 9.8% of the study population was tested for lipids. The proportion tested varied by body mass index percentile (5.9% of normal weight, 10.8% of overweight, and 26.9% of obese children) and age (8.9% of 9- to 11-year olds and 24.3% of 17- to 19-year olds). In normal weight individuals, 2.8% of 9- to 11-year olds and 22.0% of 17- to 19-year olds were tested. In multivariable models, age and body mass index category remained strongly associated with lipid testing. Sex, race, ethnicity, and blood pressure were weakly associated with testing. Abnormal lipid levels were found in 8.6% for total cholesterol, 22.5% for high-density lipoprotein-cholesterol, 12.0% for non-high-density lipoprotein-cholesterol, 8.0% for low-density lipoprotein-cholesterol, and 21% for triglycerides (age, 10-19 years). There was a strong and graded association of abnormal lipid levels with body mass index, particularly for high-density lipoprotein-cholesterol and triglycerides (2- to 6-fold higher odds ratio in obese when compared with that in normal weight children). Lipid screening was uncommon in 9- to 11-year olds and was performed in a minority of 17- to 19-year olds during 2007 to 2010. These data serve as a benchmark for assessing change in practice patterns after the new recommendations for pediatric lipid screening and management.

Guidelines for Lipid Screening in Children and Adolescents: Bringing Evidence to the Debate

* Abbreviations: CV — : cardiovascular FH — : familial hypercholesterolemia IMT — : intima media thickness LDL-C — : low-density lipoprotein cholesterol The commentary of Newman et al1 regarding recommendations for lipid screening in childhood from the expert panel guidelines commissioned by the National Heart Lung and Blood Institute2,3 misrepresents the evidence regarding screening and the specificity and rigor of the guideline development process. The expert panel developed comprehensive, integrated, and evidence-based guidelines for promotion of cardiovascular (CV) health and the identification and management of specific risk factors from infancy into young adulthood. The large, diverse, and complex evidence base that addresses CV risk beginning in childhood, and the absence of decades long event-driven clinical trials, required consideration of substantial and consistent evidence from observational studies, developing a chain of evidence. A priori, a systematic process was used to review and grade the evidence and develop the recommendations, which is explicitly described in the Full3 and Summary Reports,2 and the evidence tables are available on the National Heart Lung and Blood Institute web site.3 Atherosclerosis is a lifelong process proven to begin and progress throughout childhood and adolescence. Childhood CV risk factors track into adulthood and have been shown in many autopsy and imaging studies in diverse populations to be strongly and consistently predictive of the extent of subclinical atherosclerosis in young adults. As an example, the Pathobiological Determinants of Atherosclerosis in Youth Study of individuals aged 15 to 30 years who had died traumatically showed that a 30 mg/dL incremental increase in non-high-density lipoprotein cholesterol was the equivalent of 2 years of vascular aging.4 The Bogalusa Heart Study showed that an increasing number of childhood CV risk factors exponentially increased the atherosclerotic burden noted at autopsy after accidental death.5,6 In the Cardiovascular Risk in Young Finns Study, higher low-density lipoprotein cholesterol (LDL-C) at ages 12 to 18 years was independently … Address correspondence to Brian McCrindle, MD, MPH, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8. E-mail: brian.mccrindle{at}sickkids.ca

Universal Lipid Screening in Children and Adolescents: A Baby Step toward Primordial Prevention?

There is clear pathologic evidence that the process of atherosclerotic cardiovascular disease (CVD)2 begins in childhood with the deposition of fatty streaks within the arterial walls and subsequently progresses into fibrous plaques throughout adolescence and early adulthood. This evidence has generated a substantial interest outside of primary and secondary CVD prevention and a focus toward primordial prevention. The recent National Heart, Lung, and Blood Institute (NHLBI) Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents updated recommendations for the identification, management, and treatment of all major cardiovascular risk factors in pediatrics (1). These guidelines, which have also been endorsed by the American Academy of Pediatrics (AAP), address issues related to nutrition, physical activity, tobacco, high blood pressure, lipids, obesity, and the metabolic syndrome. One major challenge of this integrated approach is accounting for the fact that the manifestation of CVD typically occurs later in life and a variety of environmental factors influence the progression or attenuation of risk. One updated NHLBI recommendation that is likely to cause controversy is the recommendation of universal screening for dyslipidemia by the age of 9–11 years and subsequently at an age of 17–21 years. Lipid screening should be performed with either a fasting lipid panel [total cholesterol, HDL cholesterol (HDL-C), triglycerides, non–HDL-C, LDL cholesterol (LDL-C)] or a nonfasting lipid panel (total cholesterol, HDL-C, non–HDL-C). Initiatives and research emerging over the past 2 decades have led to a variety of approaches and attitudes toward screening for pediatric dyslipidemias, which have produced conflicting recommendations and variations in clinical practice. In 1992, the National Cholesterol Education Program first recommended a tiered approach to pediatric lipid screening, in which a fasting lipid profile was recommended if the child had a positive family history of premature CVD or dyslipidemia, had an unknown …

Overly Aggressive New Guidelines for Lipid Screening in Children: Evidence of a Broken Process

* Abbreviations: CVD — : cardiovascular disease NHLBI — : National Heart Lung and Blood Institute A new expert panel report1 released by the National Heart Lung and Blood Institute (NHLBI) and endorsed by the American Academy of Pediatrics2 recommends universal screening of 9- to 11-year-old children with a nonfasting lipid panel and targeted screening of 2- to 8-year-old and 12- to 16-year-old children with 2 fasting lipid profiles. These guidelines were developed in parallel with adult guidelines due out later this year, using what are described as “state-of-the art principles of evidence-based medicine.”3 The process is designed with the laudable intentions of improving transparency, keeping recommendations closely tied to the evidence, and indicating where evidence is strong and where guidelines are based on expert opinion. However, we believe that the high evidence grades for the extremely aggressive pediatric lipid recommendations are inaccurate and unjustified and that the conflicts of interest reported by panel members are too substantial to ignore. In short, these guidelines provide evidence that the NHLBI’s new “evidence-based” guideline process did not achieve its goals. The guidelines we examine here are related to lipid screening, but similar concerns apply to screening children for hypertension discussed in the same NHLBI report.1 Many of our concerns are discussed in Chapter 3 of this report, which was omitted from the supplement published in Pediatrics 2 and appears to have been ignored by the subcommittee that drafted the lipid screening recommendations. Two recent commentaries in JAMA complement our concerns as to the wisdom and appropriateness of these pediatric lipid screening guidelines.4,5 The NHLBI screening recommendations are overly aggressive. The 2- to 8-year-old and 12- to 16-year-old children for whom the panel strongly recommends 2 fasting lipid panels are those who have diabetes, hypertension, or a BMI above the 95th percentile; who smoke cigarettes; who have a parent with a total … Address correspondence to Thomas B. Newman, MD, MPH, Department of Epidemiology and Biostatistics, UCSF Box 0560, San Francisco, CA 94143. E-mail: newman{at}epi.ucsf.edu

The Anatomy of a US Preventive Services Task Force Recommendation

Differing methods for guideline development result in conflicting recommendations and clinical practice variation. This article details the approach used by the US Preventive Services Task Force to issue recommendation statements, using the 2007 recommendation for screening of lipid levels as an example. An analytic framework served as the source of key questions for a systematic review of the evidence on lipid screening in children and adolescents. Evidence was insufficient, of poor quality, or conflicting to answer 7 of the 10 questions. There was no direct evidence of the benefit of lipid screening, and insufficient evidence existed in the indirect chain of evidence to support a recommendation. In 2008, the American Academy of Pediatrics issued a clinical policy statement recommending screening for targeted children. We discuss the contrasting approach to the development of this guideline. The use of a standardized method to develop clinical guidelines promotes trust and credibility among patients and clinicians.

Hold the Statins

In a 2008 clinical report (JW Pediatr Adolesc Med Jul 16 2008), the AAP updated guidelines for lipid screening in children and adolescents. The new

To Screen or Not to Screen?

&lt;P&gt;This issue of &lt;cite&gt;Pediatric Annals&lt;/cite&gt; is devoted to office-based screening programs and the Guest Editor is David C. Grossman, MD, MPH. The nature of the screening programs comprehensively reviewed here includes pediatric office-based tobacco screening and prevention, screening for social determinants of health, lead exposure screening and prevention strategies, lipid screening in children and adolescents.&lt;/P&gt;

Lipid Screening in Children and Adolescents

Despite enormous advances in research supporting lipid screening among adults, there are critical research gaps in our understanding of the potential benefit and harm of routine screening of young children and adults. Although clear clinical opportunities exist to test and treat individual children from high risk backgrounds, building the case for systematically screening all children as part of a comprehensive cardiovascular disease prevention program requires more convincing evidence that this type of screening will yield true net positive clinical and public health outcomes. This should not prevent the pediatric community from aggressive promotion of healthy lifestyles, both in the office and through effective public policy.

An Assessment of the New Lipid Screening Guidelines

To the Editor .— The recently published “Lipid Screening and Cardiovascular Health in Childhood” clinical report from the American Academy of Pediatrics (AAP) Committee on Nutrition provides a comprehensive review of cholesterol values, atherosclerosis development, and hyperlipidemia treatment options.1 However, we do not feel that the lipid screening recommendations are justified on the basis of the narrative review. The article by Moyer et al,2 in the same issue of Pediatrics , and other similar articles have demonstrated a general analytic framework for screening tests through which we can analyze the new recommendations.3–5 Is there evidence that lipid screening of children at increased risk satisfies this framework? 1. Is there a causal relationship between childhood hyperlipidemia and adult cardiovascular events (not merely atherosclerosis)? The authors of the guidelines stated that “data …

Lipid Screening in Childhood — New Recommendations from the AAP

The AAP has released a new clinical report on lipid screening in children that replaces its 1998 policy statement. Much of the background information

Lipid Screening in Children and Adolescents

Lipid Screening in Children and Adolescents